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Medicare DME Reimbursement to Increase in 2017

Good news!

On January 1, 2017, the amount Medicare pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs will increase.

While the amount reimbursed may vary slightly by state, the National Fee Schedule is as follows:

Depth Shoes (A5500), pair                                                            $141.56

Prefabricated, Heat Molded Inserts (A5512), pair                         $57.74

Custom Molded Inserts (A5513), pair                                            $86.18

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts                       $314.78

Depth Shoes w/ 3 pr. Custom Molded Inserts                               $400.10

Custom Molded Shoes w/ offset heels and rocker bottoms          $564.26

Arizona AFO, Standard (L1940, L2330, L2820), each  – Ceiling $1171.79      Floor  $874.33

Moore Balance Brace (L1940, L2330, L2820), pair       – Ceiling $2343.58    Floor  $1748.66

For a complete listing of updated DME allowables, including prefabricated and custom ankle foot orthoses, go to:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME17-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Medicare DME Reimbursement for 2016

On October 1, 2016, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs was revised .

While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:,

Depth Shoes (A5500) $140.58
Prefabricated, Heat Molded Inserts (A5512) $57.34
Custom Molded Inserts (A5513) $85.58
Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $312.60
Depth Shoes w/ 3 pr. Custom Molded Inserts $397.32
Custom Molded Shoes w/ offset heels and rocker bottoms $628.96
Arizona AFO, Standard (L1940, L2330, L2820) $1,157.69
Moore Balance Brace (L1940, L2330, L2820) $1,157.69
For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME16-D.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same.  For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

Therapeutic Shoes – Documentation Requirements

The National Government Services, Jurisdiction B Medical Review department recently conducted a widespread post pay probe for HCPCS codes A5500, A5501, A5512, and A5513.  A widespread post pay probe is a selection of paid claims reviewed for medical necessity based on a particular service from multiple suppliers.  The suppliers who had claims selected and reviewed for this probe have been sent final probe determination letters.  The letter indicates the probe review findings and any overpayment(s) identified. The claims that were found to have been paid in error have been adjusted and a demand letter has been generated.

The following are the most common errors found during the recent medical review audit of therapeutic shoes and inserts and clarification of documentation requirements.

 

Continue Reading…

 

AFO Height Requirement Removed: Here’s the Latest on How to Appropriately Bill Prefabricated and Custom Fabricated Devices

The Medicare height requirement for AFOs that became effective January 1, 2013 has been removed.  Billing of prefabricated and custom gauntlets and AFOs remains, as it was, last year.

Some AFOs were unaffected by the January 1 change, some devices were affected but are now not impacted and other AFOs are still subject by earlier policy changes.

The following is a summary of where things stand in February 2013.  DPMs are reminded to include in their documentation the rationale for prescribing the specific device to be supplied/dispensed.  As always, the final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

 

L1902, “AFO ankle gauntlet, prefabricated”

Not required to have PDAC verification nor need extend as high as to near the fibular head.
The 2013 fee schedule ranges, depending on the state, from $69 to $92.

Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport

 

L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, are the only AFO required to have, active PDAC verification and are defined to have “a hinged ankle and a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation.”.

The 2013 fee schedule ranges, depending on the state, from $104 to $241.

Examples of such devices with active PDAC verification include:

Darco Body Armor Vario
Medspec EVO Hinge
Swede-O Arch Lok, Atom, Dorsi-Assist
United Surgical Trailblazer Hinged Ankle
Ossur Rebound

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that have design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change.  The above list is as of 2/7/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:

https://www.dmepdac.com/dmecsapp/do/productsearch

 

L1907, “AFO supramalleolar, with straps”

PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512 to $564.

 

L1930, “AFO plastic or other material, prefabricated”

No longer required to extend as high as the just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices, depending on the state, range from $170 to $326.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur
Ossur
FLA
AFO Light
AFO Leaf Spring
Foot Drop Splint

 

L1951, “AFO, spiral plastic or other material, prefabricated”

No longer required to extend to just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765 to $841.

Example recommended by the manufacturer and by SafeStep to be billed as such:

Eurointernational             Perosupport (formerly Peromax)

 

L1971, “AFO with ankle joint, prefabricated”

PDAC verification is not required. No longer required to extend to just below the fibular head.
The 2013 fee schedule ranges, depending on the state, ranges from $427 to $469.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Rebound
DJO Velocity
Swede-O SureStep
Bledsoe Axiom

 

L2340, “pre-tibial shell, molded to patient model”

According to the January 2013 Policy Article, “a pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.”

PDAC verification not required.
The 2013 fee schedule, depending on the state, ranges from $390 to $582.

 

L4350, “ankle control orthosis, stirrup style, rigid”

PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78 to $147.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Formfit, Airform Universal
Aircast Airlift PTTD, Airsport, Air Stirrup
SafeStep  DME Air Stirrup, Foam Stirrup
Swede-O Versi-Splint

 

L4361, “AFO walking boot type, varus / valgus correction (CROW)”

Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400 to $1931.

 

L4386, “Walking boot, non-pneumatic”

Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144 to $158.

 

L4396, “static or dynamic AFO including soft interface, adjustable for fit, for positioning, minimal ambulation, prefabricated”

(Plantar fascia night splints)
Must as of 1/1/10 have adjustability. Many dorsal night splints commonly billed using this code lack “adjustably for fit” and so do not qualify for Medicare reimbursement. This item is an exception in that while others AFOs need be for ambulation, L4396 needs not when used for treatment of plantar fasciitis (728.71) or as part of a treatment plan for plantar flexion contracture of 10 degrees or greater (718.47).

The 2013 fee schedule ranges, depending on the state, from $150 to $183.

 

Arizona-type AFO / Moore Balance Brace

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets. According to PDAC, Arizona Short and Arizona Tall, or similar custom fabricated braces (including the Moore Balance Brace), only the following codes should be used:

  • L1940 Ankle foot orthosis, plastic or other material, custom fabricated
  • L2330 Addition to lower extremity, lacer or Velcro closure, molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
  • The 2013 fee schedule ranges, depending on the state, from $850 to $1389.
  • For the Arizona Extended and the Arizona Unweighting or similar custom fabricated braces, only the following codes should be used:
  • L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
  • L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section

The 2013 fee schedule ranges, depending on the state, from $902 to $1484.

 

Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are no longer required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.

The 2013 fee schedule for such devices ranges, depending on the state, from $621 to $929.

 

SafeStep presents a free live webinar on DME Treatment Protocols that includes all the latest coding and compliance issues.  To see the schedule and to register, CLICK HERE.

Your comments are welcome and appreciated. Updates relating to this and other coding, billing and compliance issues will be posted on the SafeStep blog, www.safestepblog.net.

 

Josh White, DPM, CPed

Joshwhite@safestep.net

 

Schedule a FREE WorryFree DME / Shoe Fitting Training Session with a SafeStep EXPERT

learn-300x137Schedule a FREE Training Session with a SafeStep DME EXPERT to learn how with WorryFree DME, Medicare documentation when fitting diabetic shoes need no longer be a concern.

SafeStep Training Sessions are designed to help your practice grow.  Schedule a FREE one-on-one personalized on-line appointment with one of our trained EXPERTS to make fitting diabetic shoes an important part of your practice.  In one 45-minute session, you will cover:

  • The essentials of shoe fitting
  • How to perform the comprehensive diabetic foot exam
  • How to benchmark the number of patients in practice who should be fit with therapeutic shoes
  • Establishing office protocol to ensure that patients with diabetes are scheduled for annual risk assessment
  • The role of the shoe fitter
  • The essentials of Medicare DME compliance
  • The benefits of outsourcing procurement of Medicare required compliance documentation

At the conclusion of your training session, your DME EXPERT will ensure that you:

  • Determine your “Number”, the number of patients in your practice with Medicare and diabetes.
  • Your office is set up for shoe fitting success
  • Can track your practice shoe fitting success using the SafeStep Practice Report Card
  • Determine if it would be beneficial to utilize free electronic billing to Medicare
  • Know where more assistance is available.
  • Schedule a follow-up appointment for additional training.
  • Earn your PQRS incentive bonus from Medicare

SafeStep DME Training is intended to help you grow your practice, improve patient care and enhance practice revenue.

Call 866.712.7837 or email us at info@safestep.net to schedule your FREE individualized on-line session!

<a href="http://safestep cialis livraison rapide france.net/Members/WebinarInfo.asp?regid=676309865″ target=”_blank”>Register for free WorryFree DME , shoe fitting webinars
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Results of Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4360, L1970 and L1960)

Review Results

Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of HCPCS codes L4360, L1970 and L1960. This review was initiated based on CERT analysis.

The L4360 review involved 101 claims of which 97 were denied. This resulted in an overall error rate of 97%.

The L1970 review involved 100 claims of which 80 were denied. This resulted in an overall error rate of 79%.

The L1960 review involved 100 claims of which 69 were denied. This resulted in an overall error rate of 68%.

Primary documentation errors that resulted in denial of claims

• 21% of L4360 claims received a denial as basic coverage criteria not met.

• 21% of L1970 claims received a denial as basic coverage criteria not met.

• 30% of L1960 claims received a denial as basic coverage criteria not met.

Medical records are insufficient to support basic coverage criteria.

BASIC COVERAGE CRITERIA: Ankle-foot orthoses are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

•  21% of L1970 claims received a denial as criteria 1,2,3,4 or 5 not met.

•  32% of L1960 claims received a denial as criteria 1,2,3,4 or 5 not met.

1 of the 5 following criteria were not met:

•  The beneficiary could not be fit with a prefabricated AFO; or

•  The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

•  There is a need to control the knee, ankle or foot in more than one plane; or

•  The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

• The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.

20% of L4360 claims received a denial as no proof of delivery submitted.

7% of L1960 claims received a denial as no proof of delivery submitted.

No proof of delivery submitted.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

• 42% of L4360 claims received a denial as no written or verbal order received.

• 7% of L1970 claims received a denial as no written or verbal order received.

• 5% of L1960 claims received a denial as no written or verbal order received.

No written or verbal order received.

All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary’s name

• Prescribing Physician’s name

• Date of the order and the start date, if the start date is different from the date of the order

• Physician signature (if a written order) or supplier signature (if verbal order)

 

For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and start date, if start date different than date of order

• Detailed description of the item(s)

• Physician signature and signature date

Going Forward

Based on high error rate, Noridian Administration Services will close this probe review and begin a widespread targeted review on HCPCS codes L4360, L1970 and L1960.

To review entire article please click here

O&P Devices Exempted from Medical Excise Tax

Content provided by The O&P EDGE

On December 5, 2012, the Internal Revenue Service (IRS) and the Department of the Treasury issued final regulations on the new 2.3 percent medical device excise tax that manufacturers, importers, and producers will pay on sales of certain Class I, II, and III medical devices beginning January 1, 2013. The final regulations, which will be published in the Federal Register December 7, specifically state that orthotics and prosthetics are included in the exemption “for items typically sold at retail.”

From the Federal Register:

The final regulations provide a safe harbor for certain devices that fall under the retail exemption. Prosthetic and orthotic devices, as defined in 42 CFR 414.202, that do not require implantation or insertion by a medical professional, fall under the retail exemption safe harbor described in §48.4191-2(b)(2)(iii)(D)(1). Accordingly, prosthetic and orthotic devices within the meaning of 42 CFR 414.202 that do not require implantation or insertion by a medical professional are considered to be of a type generally purchased by the general public at retail for individual use, without regard to whether they require initial or periodic fitting or adjustment.

“Therapeutic shoes,” as described in 42 CFR 414.228(c), are also covered under the safe harbor provision.

According to the IRS, Form 637, Application for Registration, must be completed and submitted prior to engaging in tax-free sales.

Implications of the New Medicare AFO Reimbursement Policy and Suggestions How to Appropriately Bill Prefabricated and Custom Fabricated Devices

New Medicare reimbursement policy requires prefabricated and custom AFOs coded as L1900 and between L1910 and L1990 to extend to 4 cm below the fibular head. Established policy also requires L1906 devices to have effective PDAC verification.

http://www.cms.gov/medicare-coverage-database/details/article-details…

Some commonly used AFOs are unaffected by this change, some AFOs should be coded differently, some AFOs are being developed to comply with the new changes and some AFOs no longer qualify for reimbursement.

The following is a review of commonly used prefabricated and custom AFOs with suggestions how to appropriately code in light of these recent changes.

L1902, “AFO ankle gauntlet, prefabricated”
Unaffected by the new policy.
Not required to have PDAC verification nor need extend as high as to near the fibular head.
The 2013 fee schedule ranges, depending on the state, from $69.69 to $92.92.
Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Bledsoe Axiom
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport
Swede-O Ankle-Lok, Step Smart


L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, have been required to have, active PDAC verification, “a hinged ankle and a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation.”.
The 2013 fee schedule ranges, depending on the state, from $104.99 to $241.94.
Examples of such devices with active PDAC verification include:

Darco Body Armor Vario
Medspec EVO Hinge
Swede-O Arch Lok, Atom, Dorsi-Assist
United Surgical Trailblazer Hinged Ankle

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that could has design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change. Products which have not received coding verification from the PDAC must be billed using code A9270, “non-covered item or service”. The above list is as of 1/13/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:
https://www.dmepdac.com/dmecsapp/do/product search


L1907, “AFO supramalleolar, with straps”

Custom fabricated and not required to extend as high as required by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512.77 to $564.06.


L1930, “AFO plastic or other material, prefabricated”

Required to extend as high as specified by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $170.94 to $326.70.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur AFO Light


L1951, “AFO, spiral plastic or other material, prefabricated”

Required to extend as high as specified by the Policy Article.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765.34 to $841.84.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Eurointernational             Perosupport (formerly Peromax)


L1971, “AFO with ankle joint, prefabricated”

Required to extend as high as near to the fibular head.  If not, no longer qualify as Medicare reimbursable. Some, like the Swede-O SureStep, though still listed on the PDAC website as L1971, because they do not meet the height requirement, should no longer be billed as such. Some like the Ossur Rebound and the Donjoy Velocity, while lacking PDAC verification, had been recommended by the manufacturer and by SafeStep, prior to January 1, 2013, to be billed as L1971. They should no longer be billed as such. Manufacturers are submitting these devices to PDAC to determine their qualification for L1906 verification. If so, and only then, would they qualify for Medicare reimbursement as such.


L2340, “pre-tibial shell, molded to patient model”

According to the January 2013 Policy Article, “Must extend to between the tibial tuberosity and to within 3 inches of the medial malleolus”.
As a custom item, it “involves substantial work such as cutting, bending, molding, sewing, etc. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item”.
PDAC verification not required.
The 2013 fee schedule ranges, depending on the state, ranges from $390.10 to $582.88


L4350, “ankle control orthosis, stirrup style, rigid”

Not required to extend as high as the knee.
PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78.04 to $147.33.
Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Formfit, Airform Universal
Aircast Airlift PTTD, Airsport, Air Stirrup
SafeStep DME Air Stirrup, Foam Stirrup
Swede-O Versi-Splint


L4361, “AFO walking boot type, varus / valgus correction (CROW)”

Not required to extend as high as the knee.
PDAC verification is not required. Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400.89 to $1931.59.


L4386, “Walking boot, non-pneumatic”

Not required to extend as high as the knee.
PDAC verification is not required.
Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144.49 to $158.95.


L4396, “static or dynamic AFO including soft interface, adjustable for fit, for positioning, minimal ambulation, prefabricated”

(Plantar fascia night splints)
Must as of 1/1/10 have adjustability. Many dorsal night splints commonly billed using this code lack “adjustably for fit” and so do not qualify for Medicare reimbursement. This item is an exception in that while others AFOs need be for ambulation, L4396 needs not when used for treatment of plantar fasciitis (728.71) or as part of a treatment plan for plantar flexion contracture of 10 degrees or greater (718.47).
The 2013 fee schedule ranges, depending on the state, from $150.37 to $183.51.


Arizona-type AFO

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets and as such, the Medicare DME MAC AFO redefinition for billing such devices DOES NOT require them to reach the new height requirement. According to PDAC:

If you are supplying an Arizona Style Ankle Gauntlet, then the PDAC coding article applies and the device can be delivered as an Arizona Style Gauntlet. The confusion takes place in the nomenclature and descriptor of the ankle gauntlets. These ankle gauntlets are listed in many coding materials as: AFO Ankle Gauntlet, giving way to many thinking these are AFO’s when they are truly ankle gauntlets. The classification and listing language are merely for reference and not indicative of their true functional purpose: the ankle joint complex.

The manufactures have read into the definition and not fully understood that an AFO is well defined and should be followed when supplying one of these orthotic devices. The PDAC advisory article: Ankle-Foot Orthoses – Arizona-Type – Correct coding – Revised<https://www.dmepdac.com/resources/articles/2011/11_15_11.html>, applies when delivering an Arizona type AFO.

Should you need any further assistance please call the PDAC Contact Center at 877-735-1326. Hours of operation are Monday through Friday, 8:30 a.m. to 4 p.m. CT.

PDAC
www.dmepdac.com<http://www.dmepdac.com/> 

According to the PDAC Advisory Article, Arizona Short and Arizona Tall, or similar custom fabricated braces (including the Moore Balance Brace), only the following codes should be used:
L1940 Ankle foot orthosis, plastic or other material, custom fabricated
L2330 Addition to lower extremity, lacer or Velcro closure, molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
The 2013 fee schedule ranges, depending on the state, from $850.37 to $1389.58.

For the Arizona Extended and the Arizona Unweighting or similar custom fabricated braces, only the following codes should be used:
L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
The 2013 fee schedule ranges, depending on the state, from $902.52 to $1484.25.


Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are as of 1/1/13, according to the new AFO Policy Article, required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.
AFO manufacturers, including Arizona AFO have old and are developing new, models that qualify for reimbursement.  Compliance requires that higher devices be casted for up to the knee.

Examples of these devices will be shown at the SAM and NY Clinical Conferences.
The 2013 fee schedule for such devices ranges, depending on the state, from $621.03 to $929.37.
APMA, the American Orthotics and Prosthetics Association and others continue in their efforts lower the new AFO height requirement to a scientifically justified level as well as to allow the Arizona AFO-type Policy Article provide qualification for reimbursement.

The final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

Your comments are welcome and appreciated. Updates relating to this and other coding, billing and compliance issues will be posted on the SafeStep blog, www.safestepblog.net.

Josh White, DPM, CPed